Otolaryngology Coding Alert

Question: A non-Medicare patient with a long history of chronic rhinosinusitis presents for a second opinion on sinus surgery that another otolaryngologist has recommended. Medical management has failed, and the patient brings in old CT sinus scans.

The otolaryngologist performs a full ENT exam and a nasal endoscopy, reviews the CT scans and discusses at length with the patient the surgical risks, benefits and alternatives. Total documented face-to-face time is 65 minutes with 20 HEM-related minutes. How should I report the encounter?

Maryland Subscriber

Answer: Let’s discuss the scenario in portions:

E/M service: You should use a new patient office visit code. Your only consult option is an office visit consultation. But because a patient initiated the request for opinion, rather than a physician — which is required to bill office consultation codes 99241-99245 — you should use a new patient office visit code. Because this patient is new to the practice, assign 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient -).

Surgical discussion encounters are often the perfect opportunity to select an E/M code based on time. When counseling and or coordination of care takes 50 percent or more of an encounter’s total visit, you may base the encounter’s level on time, regardless of the documented history, exam and medical decision-making (HEM). Because in your case, counseling comprises the majority of the face-to-face encounter, you may use the visit’s time of 65 minutes to select the appropriate level of office visit: 99205, which has a reference time of 60 minutes.

Procedure: If the otolaryngologist documented a separate note for the nasal endoscopy, you should also report 31231. You will need to append modifier 25 to 99205 to show that the E/M service is significant and separately identifiable from the nasal endoscopy.

Important: To support coding an encounter based on time (if an insurer questions the service level billed), the otolaryngologist must carefully document the visit’s time breakdown (total time for the encounter and time spent for counseling and/or coordination of care) and discussion topics. For example, the physician in the surgical discussion could indicate time was spent on:

surgical option discussion

biopsy results

review of CT films

discussion of other options presented by initial ENT

medical management versus surgical management

lifestyle issues affecting medical problem, such as smoking, pets, etc.